A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"

To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line on the left side of the chest. This is the location of the apex of the heart, also referred to as the point of maximal impulse (PMI).

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Correct Answer is A

Explanation

A. Check pedal pulses every 15 min. Checking pedal pulses every 15 minutes is essential to monitor for adequate blood flow to the extremity and to detect any signs of arterial obstruction or complications at the catheter insertion site.

B. Keep the client in high-Fowler's position for 6 hr. The client should remain flat or in a low-Fowler's position to reduce the risk of bleeding at the femoral artery access site. High-Fowler's position is contraindicated.

C. Remind the client not to turn from side to side. Clients may be allowed to turn gently, but they should avoid putting pressure on the insertion site. Complete immobility is unnecessary.

D. Perform passive range-of-motion for the affected extremity. Passive range of motion is not appropriate in the immediate post-procedure period, as the extremity should remain still to prevent bleeding.

A. Elevate the head of the bed 45 degrees. B. Limit fluid intake for 4 hr after the procedure. C. Have the client rest in bed for 2 hr. D. Insert an indwelling urinary catheter 1 hr post procedure.

Correct Answer is C

Explanation

A. Elevate the head of the bed 45 degrees. The head of the bed should not be elevated this high, as this can increase pressure on the arterial access site, risking bleeding or disruption of the closure device.

B. Limit fluid intake for 4 hr after the procedure. Fluids should actually be encouraged to help flush out contrast dye used during the procedure and to maintain hydration. Limiting fluids could increase the risk of renal complications.

C. Have the client rest in bed for 2 hr. Bed rest is typically required after cardiac catheterization, especially with the use of an arterial closure device. Two hours is a reasonable time for initial bed rest following the procedure.

D. Insert an indwelling urinary catheter 1 hr post procedure. A urinary catheter is not routinely required after a cardiac catheterization unless there are specific medical indications.

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A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client immediately following a cardiac catheterization with coronary angiography. An arterial closure device was used to close the access site. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

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